Referral † to:
□
Dr
Dr
Dr
Dr
Dr
Dr
Dr
1st Available appointment
† All services and investigations are billed for all patients
or
□
David Hillman - FANZCA (Director)
Bhajan Singh - FRACP
Alan James - FRACP
Rodney Steens - FRACP
Stewart Cullen - FRACP
Nigel McArdle - FRACP
Scott Claxton - FRACP
Preferred specialist___________________________
To assign priority, it is necessary to complete this form and return it to the Sleep Disorders Clinic before an appointment can be arranged.
Thank you.
PATIENT DETAILS
REFERRING DOCTOR
NAME
ADDRESS
NAME
ADDRESS
POSTCODE
DOB
/
/
SEX
Male / Female
Ph:
(H)
(B)
Mobile:
HT:
cm WT:
kg
MEDICARE NO
PENSIONER / HEALTH CARE CARD / DVA YES / NO
(Please circle)
Ph:
E-mail:
FAX:
DATE
REFERRAL PERIOD Indefinite /
SIGNATURE
POSTCODE
/
months
PROVIDER NUMBER
CLINICAL PROBLEM / REASON FOR REFERRAL
CURRENT OCCUPATION
/
(Attach separate referral letter if more space required)
(May influence priority for consultation)
SPECIFIC PATIENT SYMPTOM INFORMATION
YES
NO
Details/Comments
Driving/Employment affected by
sleepiness/fatigue?
___________________________________
(eg dozing at lights, running off road, recent MVA)
___________________________________
COMORBIDITIES
Have any of the following conditions been diagnosed in this patient? (please tick)
Obstructive Lung Disease
eg severe COPD, asthma
Chest Wall Disease*
Vascular Disease*
Peripheral Oedema
eg CVA, TIA
(right heart failure)
Cardiac Failure
Hypertension
Hypercapnic Respiratory
Failure  arterial CO2
Ischaemic Heart Disease
Diabetes
Neuromuscular Disease*
Morbid Obesity
Other*
eg kyphoscoliosis
(BMI >50)
* Specify

MAIL OR FAX COMPLETED FORM TO:
Respiratory Sleep Disorders Clinic
Internal Mailbox 201
Queen Elizabeth ll Medical Centre
Hospital Avenue
NEDLANDS WA 6009
Tel:
(08) 9346 2422
Fax:
(08) 9346 2822
West Australian Sleep Disorders Research Institute (Inc)